Provider Demographics
NPI:1063794303
Name:LOUCKS, JENNA LEN
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LEN
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:MO
Mailing Address - Zip Code:64080-1227
Mailing Address - Country:US
Mailing Address - Phone:816-540-3161
Mailing Address - Fax:816-540-5135
Practice Address - Street 1:318 CEDAR ST
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:MO
Practice Address - Zip Code:64080-1227
Practice Address - Country:US
Practice Address - Phone:816-540-3161
Practice Address - Fax:816-540-5135
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011021982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist